1. MARTHA EPPLEY
   Posted 4 months ago #
   

   Our office is trying to implement a new software system. We have had this since September. I have found that some of the elements in the medical report are missing such as the ROS, assessment and even a history sometimes. I have been a medical coder for five years and a medical biller for 10 years and I feel very unconfortable in doing my claims. I have brought this subject up many times without resolution. In your opinion should I seek other employment? Thanks

2. SuperCoder
   Posted 4 months ago #
   

   This you may face mostly in case of Established patients which is coded on the basis of 2/3, i.e; out of History, Physical Exam, and MDM, if any of the two is documented appropriately, then you should not have any problem in coding it.
   But, if it is a New Patient, then you should ask the doctor for more info.

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